Patient falls are the most common adverse events reported in hospitals.1-5 Each year, roughly one million patient falls occur in United States (US) hospitals resulting in over 250,000 injuries and 11,000 deaths.6 Patient falls cost hospitals due to increased lengths of stay, health care expenditures, and litigation. As of March 2015, the Department of Veterans Affairs (VA) National Center for Patient Safety (NCPS) Patient Safety Information System, a confidential and non-punitive reporting system, showed that falls were the most frequently reported category of patient harm across the Veterans Health Administration (VHA).7 Although it is well understood that the physical hospital environment contributes to nearly 40% of severe or fatal hospital falls,8 there are significant gaps in our knowledge about the relationship between inpatient unit design and fall rates. The few studies that have examined unit design have been conducted in a single hospital or a small number of inpatient units, limiting generalizability.9,10 Furthermore, there have been no studies focused on unit design and falls in VA medical centers (VAMCs). The VA's Office of Construction and Facilities Management promotes evidence-based design.11 Thus, the overarching goal of this study is to identify unit design factors contributing to inpatient falls within the VHA. This study addresses Strategy 6.3 of the 2014 VA Blueprint for Excellence12 and Objective 3.3 of the 2014-2020 VA Strategic Plan13 both of which emphasize design of VA space. Specifically, the Strategic Plan states that ?VA will continue capital planning efforts to provide safe, secure, modern, and sustainable infrastructure?? Our research will directly inform the VA's efforts to renovate or build physical spaces that improve Veterans' safety. To accomplish this, we are proposing a mixed methods study to explore the relationship between unit design and patient falls in VA medical/surgical (med/surg) units. We will utilize a qualitative approach to investigate staff and management perceptions with environmental factors that contribute to patient falls (Aim 1). We will use quantitative approaches in Aim 2 to identify med/surg units with higher- or lower-than expected fall rates and identify spatial and environmental factors that distinguish them. The specific aims of this study are to: Aim 1: Investigate front-line and management perceptions of and experiences with Veteran falls as they pertain to inpatient environmental factors. We will conduct walk-through interviews in 12 med/surg units at the Malcom Randall VAMC in Gainesville, the Lake City VAMC in Lake City, and the James A. Haley Veterans' Hospital in Tampa with unit and facility personnel to identify environment-related fall risk factors at each site. Interview findings will directly inform the development of an Environmental Assessment Survey to be conducted as part of Aim 2, as well as, contribute to interpretation of Aim 2 results. Aim 2: Quantify associations between unit design factors and fall rates by comparing spatial and environmental factors of units with higher- versus lower- than expected fall rates. We will use fall data from the VA Inpatient Evaluation Center (IPEC) and patient data from additional data sources to identify med/surg nursing units with higher- than expected (n = 25), and lower- than expected (n = 25), fall rates. Once these units are identified, we will measure spatial factors, analyzing computer aided design (AutoCAD) files of unit floorplans, and environmental factors, based on the Environmental Assessment Survey developed in Aim 1. Statistical tests will then be performed to identify those design factors that distinguish high and low outliers.